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410 Statement of Organization Recipient Committee – Initial Not yet qualified Statement of Organization D © Lnie Um V [ CALIFORNIA 410 Recipient Committee FORM ' Statement Type 21 Initial 0 Amendment 0 Termination—See Part5 MAR For Official Use Only Notyetquallfed Erb or List I.D.number: List I.D.number: -. Midi — ZDIU CL PERTINO CITY CLERK Date qualified as committee Date qualified as committee Date of Termination (If applicable) 1.. Committee Information 2. Treasurer and Other Principal Officers I NAME OF COMMITTEE NAME OF TREASURER David Fung for City Council 2016 Kathy Jacques STREET ADDRESS(NO P.O.Bo)0 STREET ADDRESS(NO P.O.Box) CITY STATE ZIP CODE AREA CODE/PHONE Cupertino CA 95014 ( CITY STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER,IF ANY Cupertino CA 95014 ( MAILING ADDRESS(IF DIFFERENT) STREET ADDRESS(NO P.O.BOX) FAX/E-MAILADDRESS CITY STATE ZIP CODE AREA CODE/PHONE COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE NAME OF PRINCIPALOFFICER(S) Santa Clara Cupertino, CA STREET ADDRESS(NO P.O.BOX) CITY STATE ZIP CODE AREA CODE/PHONE Attach additional information on appropriately labeled continuation sheets. 3. Verification i I have used all reasonable diligence in preparing this statement and to the best of my knowledge the information contained herein is true and complete. I certify under penalty of perjury under the laws of the State of Gafford li aforegoing is true and cor • r Executed on 02/29/2016 By � DATE SIGNATURE OF CONTROLLING OFFICEHOLDER,CANDIDATE,OR STATE MEASURE PROPONENT Executed on By DATE SIGNATURE OF CONTROLLING OFFICEHOLDER,CANDIDATE,OR STATE MEASURE PROPONENT FPPC Form 410(Jan/2016) FPPC Advice:advice@fppc.ca.gov(866/275-3772) www.fppc.ca.gov Statement of Organization CALIFORNIA 410 Recipient Committee FORM INSTRUCTIONS ON REVERSE Page 2 ' COMMITTEE NAME I.D.NUMBER David Fung for City Council 2016 • All committees must list the financial institution where the campaign bank account is located. NAME OF FINANCIAL INSTITUTION - AREA CODE/PHONE BANK ACCOUNT NUMBER Pending ID # ADDRESS CITY STATE ZIP CODE 4.Type.,of'Committee. Complete-the applicable sections. Controlled Committee • List the name of each controlling officeholder,candidate,or state measure proponent. If candidate or officeholder controlled,also list the elective office sought or held,and district number,if any,and the year of the election. • List the political party with which each officeholder or candidate is affiliated or check"nonpartisan." • If this committee acts jointly with another controlled committee,list the name and identification number of the other controlled committee. ELECTIVE OFFICE SOUGHT OR HELD NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY ▪ Nonpartisan David Fung Cupertino City Council 2016 ❑ Nonpartisan Primarily Formed Committee Primarily formed to support or oppose specific candidates or measures in a single election. List below: CANDIDATE(S)NAME OR MEASURE(S)FULL TITLE(INCLUDE BALLOT NO.OR LETTER) CANDIDATE(S)OFFICE SOUGHT OR HELD OR MEASURE(S)JURISDICTION (INCLUDE DISTRICT NO.,CITY OR COUNTY,AS APPLICABLE) CHECK ONE SUPPORT OPPOSE ❑ n SUPPORT OPPOSE FPPC Form 410(Jan/2016) FPPC Advice:advice@fppc.ca.gov(866/275-3772) www.fppc.ca.gov